OMB CONTROL NO. 2090

- 0030

APPROVED: 05/01/2008

APPROVAL EXPIRES: 12/22/2013



### MBE/WBE UTILIZATION UNDER FEDERAL GRANTS

AND COOPERATIVE AGREEMENTS
PART I. (Reports are required even if no procurements are made during the reporting period.)

1A. FEDERAL FISCAL YEAR

(Oct. 1

- Sep 30)

20_______ 1B. REPORTING PERIOD (Check ALL appropriate boxes)

□ 1 st (Oct

- Dec) □ 2 nd (Jan

- Mar) □ 3 rd (Apr

- Jun) □ 4 th (Jul

- Sep)

□ Semi

- Annual (Oct

- Mar) □ Semi

- Annual (Apr

- Sep)

□ Annual

□ Check if this is the last report for the project (Project completed).

1C. REVISION OF A PRIOR REP ORT? Y

or N Year: _________ Quarter: _________ BRIEFLY DESCRIBE THE REVISIONS YOU ARE MAKING:

2A. EPA FINANCIAL ASSISTANCE OFFICE ADDRESS ( ATTN: DBE Coordinator) 3A. RECIPIENT NAME AND ADDRESS

2B. EPA DBE COORDINATOR

Name:

E

- mail: 2C. PHONE:

Fax: 3B. RECIPIENT REPORTING CONTACT:

Name:

E

- mail: 3C. PHONE:

Fax:

4A. FINANCIAL ASSISTANCE AGREEMENT ID NUMBER
(SRF State Recipients, refer to Instructions for Completion of blocks 4A, 5A and 5C.) 4B. FE DERAL FINANCIAL ASSISTANCE PROGRAM TITLE or CFDA

NUMBER:

5A. TOTAL ASSISTANCE AGREEMENT AMOUNT
(SRF State Recipients, refer to Instructions for Completion of blocks 4A, 5A and 5C.)

EPA Share: $_______________________

Recipien t Share: $_____________________ 5B. If NO procurement and NO accomplishments were made this reporting period ( by the recipients, sub

- recipients, loan rec ipients, and prime contractors)

, CHECK and SKIP to Block No. 7. ( Procurements are all expenditures through contract, order, purchase, lease or barter of supplies, equipment, construction, or services needed to complete Federal assistance

programs. Accomplishments , in this context, are procurements made with MBEs and/or WBEs.

□

5C. Total Procurement s This Reporting Period
(Only include amount not reported in any prior reporting period)

Total Procurement Amo unt $________________________ (Include total dollar values awarded by recipient, sub

- recipients and SRF loan recipients

, including MBE/WBE expenditures

. )

5D.

Were sub

- awards issued under this assistance agreement? Yes___ No____ Were contracts issued under this assistance agreement ? Yes____ No___

5E. MBE/WBE Accomplishments This Reporting Period

Actual MBE/WBE Procurement Accomplished: (Include total dollar values awarded by recipient, sub

- recipients, SRF loan recipients and Prime Contractors.)

Construction Equipment Services Supplies Total

$MBE:

____________ _____________ _____________ _____________ _____

___________

$WBE:

____________ ______________ ______________ _____________ ________________

6. COMMENTS: (If no MBE/WBE procurements were accomplished during the reporting period, please explain what steps you are ta king to achieve the MBE/WBE Program requirements specified in the terms and conditions of the Assistance Agreement.)

7. NAME OF RECIPIENT’S AUTHORIZED

R EPRESENTATIVE TITLE

8. SIGNATURE OF RECIPIENT’S AUTHORIZED

REPRESENTATIVE DATE

EPA FORM 5700-52A available electronically at http://www.epa.gov/osbp/pdfs/5700_52a.pdf United States ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

### PART II. MBE/WBE PROCUREMENTS MADE DURING REPORTING PERIOD EPA Financial Assistance Agreement Number: _______________

Type of product or service codes:

1 = Construction 2 = Supplies 3 = Services 4 = Equipment
Note: Refer to Terms and conditions of your Assistance Agreement to determine the frequency of reporting. Recipients are required to submit MBE/WBE reports to EPA beginning with the Federal fiscal year quarter the recipients receive the award, continuing until the project is completed.

EPA FORM 5700- 52 A - (Approval Expires 12/22/13) 1. Procurement Made By 2. Business Enterpris e 3. $ Value of

Procurement 4. Date of

Procurement

MM/DD/YY 5. Type of

Product or

Services A (Enter Code) 6. Name/Address/Phone Number of MBE/WBE

Contractor or Vendor

Recipient Sub

Recipient

and/or SRF

Loan Recipient Prime Minority Women

# Instructions:

A. General Instructions:

MBE/WBE utilization is based on 40 CFR Part 33. EPA Form 5700-52A must be completed by recipients of Federal grants, cooperative agreements, or other Federal financial assistance which involve procurement of supplies, equipment, construction or services to accomplish Federal assistance programs.

Reci pients are required to report 30 days after the end of each federal fiscal quarter, semiannually, or annually, per

the terms and conditions of the financial assistance agreement.

Quarterly

Reporting

Due Date Semiannual

Reporting

Due Date Annual

Reporting

Due Date

Agreements

awarded prior to May
27, 2008 January 30,

April 30, July 30,

Octob er 30 N/A October

30

Agreements

awarded on

or after May
27, 2008 N/A April 30,

October 30 October

30

MBE/WBE program requirements, including reporting, are

material terms and conditions of the financial assistance agreement.

B. Definitions:

Procurement is the acquisition through contract, order, purchase, lease or barter of supplies, equipment, construction or services needed to accomplish Federal assistance programs.

A contract is a written agreement between an EPA recipient and another party (also considered “prime contracts”) and any lower tier agreement (also considered “subcontracts”) for equipment, services, supplies, or construction necessary to complete the project. This definition excludes written agreements with another public agency. This definition includes personal and professional services, agreements with consultants, and purchase orders.

A minority business enterprise (MBE) is a business concern that is (1) at least 51 percent owned by one or more minority individuals, or, in the case of a publicly owned business, at least 51 percent of the stock is owned by one or more minority individuals; and (2) whose daily business operations are managed and directed by one or more of the minority owners. In order to qualify and

par ticipate as an MBE prime or subcontractor for EPA recipients under EPA’s DBE Program, an entity must be properly certified as required by 40 CFR Part 33, Subpart

B.

U.S. citizenship is required. Recipients shall presume that minority individuals include Black Americans, Hispanic Americans, Native Americans, Asian Pacific Americans, or other groups whose members are found to be disadvantaged by the Small Business Act or by the Secretary of Commerce under section 5 of Executive order 11625. The reporting contact at EPA can provide

additional information.

A woman business enterprise (WBE) is a business concern that is, (1) at least 51 percent owned by one or more women, or, in the case of a publicly owned business, at least 51 percent of the stock is owned by one or more women and (2) whose daily business operations are managed and directed by one or more of the women owners. In order to qualify and participate as a WBE prime or subcontractor for EPA recipients under EPA’s DBE Program, an entity must be properly certified as required by 40 CFR Part 33, Subpart B.

Business firms which are 51 percent owned by minoritiesor women, but are in fact managed and operated by nonminority individuals do not qualify for meeting MBE/WBE procurement goals. U.S. Citizenship is required.

Good Faith Efforts

A recipient is required to make the following good faith efforts whenever procuring construction, equipment, services, and supplies under an EPA financial assistance agreement. These good faith efforts for utilizing MBEs

and WBEs must be documented. Such documentation is subject to EPA review upon request:

1. Include of MBEs/WBEs on solicitation lists.

2. Assure that MBEs/WBEs are solicited once they

are identified.

3. Divide total requirements into smaller tasks to permit maximum MBE/WBE participation, where

feasible.

4. Establish delivery schedules which will encourage MBE/WBE participation, where feasible.

5. Encourage use of the services of the U.S. Department of Commerce's Minority Business Development Agency (MBDA) and the U.S. Small Business Administration to identify MBEs/WBEs.6. Require that each party to a subgrant,

subagreement, or contract award take the good

faith efforts outlined here.

C. Instructions for Part I:

1a. Specify Federal fiscal year this report covers. The

Federal fiscal year runs from October 1 st through
September 30 th ( e.g. November 29, 20 10 falls within Federal fiscal year 20 11 )

1b. Check applicable reporting box, quarterly

, semiannually, or annually. Also indicate if this is the last report for the project. 1c. Indicate if this is a revision to a previous year

, half-year, or quarter, and provide a brief description of the revision you are making.

2a -c. Please refer to your financial assistance agreement for the mailing address of the EPA financial assistance office for your agreement.

The “EPA DBE Reporting Contact” is the DBE Coordinator for the EPA Region from which your financial assistance agreement was originated. For a list of DBE Coordinators please refer to the EPA OSBP website at www.epa.gov/osbp. Click on “Regional Contacts” for the name of your

coordinator.

3a -c. Identify the agency, state authority, university or other organization which is the recipient of the Federal financial assistance and the person to contact concerning this report.

4a. Provide the Assistance Agreement number assigned by EPA. A separate report must be submitted for each Assistance Agreement.

*For SRF recipients : In box 4a list numbers for ALL OPEN Assistance Agreements being reported on this form

. Please note that although

the N ew DBE Rule (which took effect May 27

, 2008) revised the reporting frequency requirements from quarterly to semiannually, that change only applies to agreements awarded

AFTER the New DBE Rule took effect. Therefore, SRF recipients may either continue to report activity for all Agreements on one form on a quarterly basis until the last award that was made prior to the New DBE Rule has been closed out; OR, the recipient may split the submission of

SR F reports into quarterly reports for Agreements awarded prior the New DBE Rule, and semiannually for the awards made after the New

DBE Rule. 4b. Refer back to Assistance Agreement document

for this information.

5a. Provide the total amount of the Assistance Agreement which includes Federal funds plus recipient matching funds and funds from other

sources.

*For SRF recipients only : SRF recipients will not

enter an amount in 5a. Please leave 5a blank.

5b. Self-explanatory.

5c. Provide the total dollar amount of ALL procurements awarded this reporting period by the recipient , s ub -recipients, and SRF loan recipients

, including MBE/WBE expenditures.

F or example: Actual dollars for procurement from the procuring office; actual contracts let from the contracts office; actual goods, services, supplies, etc., from other sources including the central purchasing/ procurement centers).

*NOTE : To prevent double counting on line 5C, if any amount on 5E is for a subcontract and the prime contract has already been included on Line 5C in a prior reporting period, then report the amount going to MBE or WBE subcontractor on line 5E, but exclude the amount from Line 5C. To include the amount on 5C again would result in double counting because the prime contract,

wh ich includes the subcontract, would have already been reported.

5d. State whether or not sub-awards and/or

subcontracts have been issued under the assistance agreement by indicating “yes” or “no”.

5e. Where requested, also provide the total dollar amount of all MBE/WBE procurement awardedduring this reporting period by the recipient, subrecipients, SRF loan recipients, and prime contractors in the categories of construction, equipment, services and supplies. These amounts include Federal funds plus recipient matching funds and funds from other sources.

*For SRF recipients only : In 5c please enter the total procurement amount for the quarter, or semiannual period, under all of your SRF Assistance Agreements. The figure reported in

this section is not directly tied to an individual Assistance Agreement identification number. (SRF state recipients report state procurements in this section)

6. If there were no MBE/WBE accomplishments this reporting period, please briefly explain whatspecific steps you are taking to achieve the

MBE/WBE requirements specified in the terms and conditions of the Assistance Agreement.

7. Name and title of official administrator or designated reporting official.

8. Signature, month, day, and year report submitted.

D. Instructions for Part II:

For each MBE/WBE procurement made under this assistance agreement during the reporting period, provide the following information:

1. Check whether this procurement was made by the recipient, sub-recipient/SRF loan recipient, or the prime contractor.

2. Check either the MBE or WBE column. If a firm is both an MBE and WBE, the recipient may choose to count the entire procurement towards EITHER its MBE or WBE accomplishments. The recipient may also divide the total amount of the procurement (using any ratio it so chooses) and

count those divided amounts toward its MBE and WBE accomplishments. If the recipient chooses to divide the procurement amou nt and count portions toward its MBE and WBE accomplishments, please state the appropriate

amounts under the MBE and WBE columns on

the form. The combined MBE and WBE

amounts for that MBE/WBE contractor must

not exceed the “Value of the Procurement” reported in column #3

3. Dollar value of procurement.

4. Date of procurement, shown as month, day, year. Date of procurement is defined as the date the contract or procurement was awarded, not the date the contractor received payment under the awarded contract or procurement, unless payment occurred on the date of award. (Where direct purchasing is the procurement method, the date of procurement is the date the purchase was made)

5. Using codes at the bottom of the form, identify type of product or service acquired through this procurement (e. g., enter 1 if construction, 2 if supplies, etc).

6. Name, address, and telephone number of

MBE/WBE firm.

** This data is requested to comply with provisions mandated by: statute or regulations (40 CFR Part 30, 31, and 33); OMB Circulars; or added by EPA to ensure sound and effective assistance management. Accurate, complete data are required to obtain funding, while no pledge of confidentiality is provided.

The public reporting and recording burden for this collection of information is estimated to average l hour per response annually. Burden means the total time, effort, or financial resources expended by persons to generate, maintain, retain, or disclosure or provide information to or for a Federal agency. This includes the time needed to review instructions; develop, acquire, install, and utilize technology and systems for the purposes of collecting, validating, and verifying information, processing and maintaining information, and disclosing and providing information; adjust the existing ways to comply with any previously applicable instructions and requirements; train personnel to be able to respond to a collection of information; search data sources; complete and review the collection of information; and transmit or otherwise disclose the information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid

OMB control number.

Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, OPPE Regulatory Information Division, U.S. Environmental Protection Agency (2136), 1200 Pennsylvania Avenue, NW, Washington, D.C. 20460. Include the OMB Control number in any correspondence. Do not send the completed form to this address.